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Health Department

Health Department

Report of the
1999-2000 San Francisco Civil Grand Jury

 

  • SUMMARY

    Members of the Civil Grand Jury (CGJ) investigated various problems at San Francisco General Hospital (SFGH), including the following: long waiting periods of up to five hours for prescriptions and clinic appointments, inadequate staffing in the urgent care clinic, a high incidence of diverting emergency room patients to other medical facilities, excessive overtime costs resulting from unfilled positions, and delayed responses – sometimes no response – to telephone calls from people seeking appointments or information.

    The CGJ concluded that SFGH should not close or privatize the pharmacy and that the clinic should be fully staffed and properly maintained. The CGJ further concluded that, for SFGH to continue providing essential services to the people of San Francisco, the hospital budget should be separated from the Department of Public Health (DPH) budget and that there should be increased citizen participation in long-range planning. The conclusions and recommendations in this report are based on information and events as of June 30, 2000.


    BACKGROUND

    DPH runs two large public hospitals, SFGH and Laguna Honda, and a network of neighborhood health centers and clinics. DPH traditionally has provided services to the mentally disabled, seniors, and children, low-income families and people on welfare. In spite of general improvements in the economy, new classes of the working poor have emerged who are faced with escalating housing and health care costs.

    Beginning in the late 1960s several emerging populations with special needs have come increasingly to use and rely on the health care services provided by SFGH: the arrival of new immigrants from all over the world, the impetus of the flower children era when drug use became commonplace, the AIDS epidemic and the gay community’s emergence as a social and political force, the emphasis on women's health and social issues, San Francisco's becoming a Sanctuary City for refugees from Central America, and significant numbers of the homeless and the uninsured having to depend upon SFGH for their total health needs.

    San Francisco, a city of diversity, has special needs that have been met traditionally by a caring public health institution, SFGH. SFGH, ranked the second best medical care facility among all hospitals in the city in 1998, has responded to these needs by providing care to a significant number of homeless people who have drug and alcohol problems and are mentally ill. SFGH has developed the nation’s foremost AIDS program and has received national acclaim for its Trauma Center and psychiatric care units. SFGH has created and continues to maintain a network of neighborhood health centers and clinics.

    The current budget of the San Francisco Health Care System is $928 million. One half, or $467 million, goes to SFGH. During the past six years, the county’s health system has faced mounting fiscal shortfalls that require a growing portion of the General Fund budget. As a result of funding cuts by the state and federal governments, combined with increased costs of caring for the indigent and uninsured and other inflationary factors unique to health care, DPH administrators are projecting a budget shortfall this fiscal year of at least $20 million. San Francisco's fiscal crisis isn’t unique; health departments throughout the state and country are having similar budget shortfalls as a result of substantial decreases in state and federal funding. This year San Francisco is losing more than $23 million in federal and state funding. Public officials have responded to the shortfalls with various measures and proposals. Although $230 million was allocated from the General Fund monies to the DPH budget, a hiring freeze was imposed during the 1999-2000 fiscal year, leaving many positions vacant and forcing health care staff to work overtime. In a press release from the Office of the Mayor dated May 31, 2000, the budget presented for 2000-01 "calls for $20 million in new General Fund dollars to replace lost federal and state revenues at SFGH (during the Brown administration, general fund support to the Department of Public Health has increased 133 percent)...."

    According to media reports, Dr. Mitchell Katz and the DPH administration have proposed the following cuts in services:

  • Closing the Potrero Hill Health Center;
  • Cutting 21 beds from psychiatric care and moving the displaced patients to a Mission District hotel converted to a halfway house;
  • Closing or privatizing the outpatient pharmacy at SFGH;
  • Focusing less on acute care and more on preventive care.

    Community activists, patient advocate groups, members of the Board of Supervisors, doctors, nurses and other health care employees at SFGH, and health care professionals throughout the city have opposed the proposed cuts. Community activists mounted sufficient opposition to force DPH administration to abandon its plan to merge the Potrero Hill Health Center with the clinics at SFGH.

    Doctors, nurses, and other staff at SFGH who oppose eliminating 21 beds in the psychiatric unit and involuntarily reassigning staff to other hospitals argue that the cutbacks and transfers will undermine the quality of care for the mentally ill. Apparently in agreement, the Board of Supervisors delayed this action in May 2000. DPH administration has indicated that the transfers will not take place if a controller’s audit shows that the reassignments would effect no savings. DPH claims the patients to be transferred do not require the acute care beds they now occupy but at present there is no alternative site for their care.

    Individuals and groups that oppose closing or privatizing the pharmacy at SFGH argue that the low-income, disabled and medically indigent people would not receive the same level of service from private sector pharmacies that SFGH has provided and that those pharmacies would not be able or inclined to provide to the homeless the assistance they need in obtaining their prescriptions; consequently, without medication many of those patients would have to be treated in the emergency room, which would be much more expensive. In April 2000, a community coalition initiated a lawsuit in San Francisco Superior Court to keep the pharmacy open and to hire sufficient staff to cut the waiting time for filling prescriptions to a half-hour. That lawsuit is pending.

    In San Francisco, one of the few remaining counties with a general hospital, private hospitals provide a proportionally smaller share of care for poor and uninsured patients than those in other California counties. During 1998, San Francisco's private hospitals provided only six percent of the county’s entire indigent and charity care, while SFGH delivered the remainder.

    Data from DPH indicate that the number of uninsured patients treated at SFGH has increased sharply during the past six years. The number of uninsured patients utilizing acute-care services at SFGH has grown by 35 percent from 4,284 patients in Fiscal Year (FY) 1993-94 to 5,783 patients in FY 1998-99. The uninsured patients have grown not only in absolute numbers, but also as a percentage of SFGH’s total acute-care patient population: from 29 percent of SFGH’s acute-care patient population in FY 1993-94 to 40 percent in FY 1998-99.


    METHODOLOGY

    The CGJ decided to investigate various problems at SFGH, including:

    1. Reported waiting periods of up to five hours to have prescriptions filled;

    2. Long waits for clinic appointments;

    3. Inadequate staffing in the urgent care clinic;

    4. A high incidence of diversion of emergency room patients to other medical facilities;

    5. Unfilled positions contributing to excessive overtime costs and delayed responses – sometimes no response – to telephone calls from patients.

     

    One of the main concerns of the CGJ was that older and infirm patients, people in pain and with chronic illnesses, as well as other patients, have had to wait for periods of up to five hours for their prescriptions. In several visits to SFGH, members of the CGJ met with administrators, doctors, nurses, other staff and community groups, and also visited hospitals, including Kaiser Permanente, and neighborhood pharmacies throughout the city to form some basis for comparison.

    The CGJ has also been concerned about the closing of emergency rooms during the past decade at the following hospitals: French, Mount Zion, Children’s and Letterman. With the deactivation of the Presidio Army Base, there is no longer an opportunity to have the military assist in moving patients to other Bay Area hospitals. In the event of a major earthquake, another natural disaster or a large-scale emergency, the general lack of emergency care in the city would be compounded.


    CONCLUSIONS

    The CGJ focused its review on the SFGH pharmacy issue because of an ongoing problem of patients waiting three to five hours or days for a prescription. This problem has lasted 10 years. From our interviews with pharmacists and other health care professionals at hospitals and neighborhood pharmacies, we learned that, given the ratio of pharmacists and support staff to the number of prescriptions filled, the workload does not warrant waiting for up to five hours for prescriptions. The time taken to fill prescriptions at other hospitals and neighborhood pharmacies throughout the city generally takes 10 to 30 minutes. Kaiser Permanente has been able to lower costs by ordering drugs in large quantities enabling prescriptions to be packaged in quantities of 30, 50, or 100. At their new facility in San Francisco, Kaiser has established smaller pharmacies on every floor, and reports that has increased efficiency.

    CGJ members share the concerns expressed by neighborhood pharmacists, community activists and other health care workers that closing or privatizing the pharmacy would result in further deterioration in service.

    The long waiting time for clinic appointments is unacceptable but is not a "high priority" item for DPH. According to DPH administration, there are more critical needs for budget dollars. The department’s hiring freeze has led to insufficient staff in the urgent care clinic, excessive overtime costs and increased diversion of people requiring emergency room treatment to other hospitals. The lack of staff has also delayed responses to telephone calls from people seeking information or appointments. Instead of determining how DPH can provide essential services, DPH administration appears to be more concerned with making cuts.


    RECOMMENDATIONS

    In view of our conclusions, the CGJ recommends the following:

    1. Instead of closing or privatizing the pharmacy, SFGH should open a second pharmacy. SFGH should also replicate, wherever feasible, Kaiser Permanente’s efficiency measures in dispensing prescriptions. The goal is to minimize the excessively long waiting time for prescriptions.

    Required Response

    Department of Public Health
    Health Commission


    2. DPH should approach major software producers for their expertise and assistance in upgrading its computer system since a highly efficient and sophisticated computer system, like Kaiser's and that of many neighborhood pharmacies, would make dispensing medication more efficient.

    Required Response

    Department of Public Health
    Health Commission


    3. Fill the staffing vacancies in the clinics to cut the long delays in getting an appointment. A reasonable goal would be to set an appointment within seven to fifteen days after a patient makes a request by telephone or consults a doctor.

    Required Response

    Department of Public Health
    Health Commission


    4. Ensure that neighborhood health centers function at full staffing levels since they provide critical preventive care and language assistance in the neighborhoods that they serve.

    Required Response

    Department of Public Health
    Health Commission


    5. Provide urgent clinical care and extend the hours to eliminate or minimize the need for patients requiring non-acute care to seek treatment in the emergency room. Doing so would provide some relief to overextended emergency room staff and would decrease the need to divert patients who need critical and immediate emergency care to other hospitals.

    Required Response

    Department of Public Health
    Health Commission


    6. Continue providing the current level of in-house psychiatric care to the mentally ill since the strong family involvement program, the specialized and culturally sensitive care to a diverse population, and the multilingual capabilities to help the limited-English speaking and monolingual patients have all contributed significantly to the quality of the care.

    Required Response

    Department of Public Health
    Health Commission


    7. Develop a comprehensive citywide plan to ensure that the residents of San Francisco have access to essential emergency room services during normal circumstances and during crises arising from earthquakes, other natural disasters, terrorist attacks, or any other emergency, and present that comprehensive plan to the Health Commission.

    Required Response

    Board of Supervisors
    Department of Public Health
    Health Commission
    Office of Emergency Services


    8. Take the necessary procedural steps to separate administratively and actually the budget of SFGH and clinics from the budget of DPH to ensure that funding to provide essential medical care is not diverted to other well-intentioned programs and services that address broader societal concerns but are peripheral to the health care that SFGH has provided in the past and should continue to provide to the people of San Francisco.

    Required Response

    Mayor
    Board of Supervisors
    Department of Public Health
    Health Commission


    9. Based on the perception of the CGJ that there is a critical lack of long-range planning in DPH; DPH should comply with the City Charter requirement that all departments have a functional three-year plan, thus enabling DPH to make realistic budget projections rather than reacting precipitously to recurring deficits. DPH should formulate this plan after there is sufficient input, via public forums, from all affected parties.

    Required Response

    Board of Supervisors
    Department of Public Health
    Health Commission

  • Last updated: 9/15/2009 12:47:32 PM